the september 2005 e coli o157 outbreak in south wales l.
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The September 2005, E.coli O157 Outbreak in South Wales. Paul J Mee, Service Director for Public Health & Protection & Julie Barratt, Director CIEH Wales. Wrexham Outbreak – August 2009. Surrey Outbreaks-September 2009. Introduction. Outbreak Control Plan Declaration of the Outbreak

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The September 2005, E.coli O157 Outbreak in South Wales

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the september 2005 e coli o157 outbreak in south wales

The September 2005, E.coli O157 Outbreak in South Wales

Paul J Mee, Service Director for Public Health & Protection


Julie Barratt, Director CIEH Wales


Wrexham Outbreak – August 2009

Surrey Outbreaks-September 2009

  • Outbreak Control Plan
  • Declaration of the Outbreak
  • Initial Investigation & Control
  • J Tudor & Son, Bridgend
  • Control Measures
  • Detailed Investigations & Results
  • Communications, Politics & the Media
  • Chief Medical Officers Review
  • Police Investigation
  • The Local Authority Prosecution
  • What have we learned?
  • Response to Public Inquiry Recommendations
e coli o157
Highly virulent – low infective dose

1-14 days incubation period

Can cause complications such as HUS and is sometimes fatal

Young and elderly particularly vulnerable

Prolonged asymptomatic excretion

High risk of secondary spread

E.coli O157
outbreak control plan
Outbreak Control Plan
  • Devolved administration – Welsh Assembly Government
  • 22 Unitary Local Authorities
  • Local Health Boards
  • National Public Health Service for Wales
    • Consultant in Communicable Disease Control
    • NPHS laboratory services
    • Regional Epidemiologists & CD Surveillance Centre
  • Model Outbreak Control Plan
  • Lead Officer for Communicable Disease
the outbreak control team oct
The Outbreak Control Team (OCT)
  • Chaired by CCDC, supported by regional epidemiologists, consultant microbiologist
  • EH representatives of all LA’s
  • Local Health Board – Local Public Health Director
  • Food Standards Agency
  • Also from Rhondda Cynon Taf:
    • Local Education Authority
    • Catering Direct
    • Communications
outbreak declaration
Outbreak Declaration
  • Friday 16th September 2005 – first 8 cases notified to NPHS following hospital admissions
  • Further 2 cases confirmed by NPHS laboratory via +ve stool specimens
  • Incident meeting convened that afternoon – 2 further cases added to list
  • Outbreak declared and OCT formed
initial investigation control measures
Initial Investigation & Control Measures
  • Fast Food Outlet
  • Swimming Pool
  • School Meals
    • Menus
    • Milk
    • Water coolers
    • Fruit tuck shops
  • Cooked sliced meats
  • Meat supplier
  • School kitchens/School Inspections
initial investigations control
Initial Investigations & Control
  • Sunday 18th September – decision to remove all cold cooked & sliced meat from school meals
  • Catering staff urgently contacted so that meat removed and stored separately for collection by EHOs
  • Inspections of meat supplier on 19th & 20th September
  • Emergency prohibition notices – risk of cross contamination from vac packing process; unsanitary condition of premises
tudor son butchers bridgend
Tudor & Son Butchers, Bridgend
  • Vacuum packer & weighing scales used for raw & cooked meats
  • No sanitizer on the premises so equipment could not have been cleaned between use
  • Cooked meat brought into raw meat preparation area to be weighed and packed
  • Cooked meats stored in boxes previously containing raw meat
  • Vacuum packer located immediately adjacent to mincing machine
  • Failure to follow HACCP document stipulating separation of raw and cooked meat
numerous food hygiene offences
Vacuum packer dirty & greasy

Fly killer positioned directly above vacuum packer

Floor covering in poor condition

Walls dirty and marked with blood splashes

Grills to floor drains had gaps allowing past access

Band saw unit dirty with food debris

Walk in freezer iced up & stocked haphazardly

Wash hand basin leaking causing water to pool on floor

Meat slicer dirty

Table dirty

Walls of walk in chiller were dirty

Drain blocked with food debris

Light covers were dirty with flies & insects

Numerous food hygiene offences
control measures
Control Measures
  • Removal of cold & cooked sliced meats from school meals
  • FSA - Food Alert for Action – 21st September – removing all cooked meat supplied by Tudors Butchers from the food chain
control measures spread of infection
Control Measures – Spread of Infection
  • Verbal advise and advisory leaflets to all cases
  • Exclusion of cases & case contacts from school & work
    • Risk groups identified in accordance with national guidelines
    • Suspected cases & contacts until screened
    • Children under 6 years of age within affected families
    • 2 –ve samples at least 48 hours apart obtained
control measures spread of infection14
Control Measures – Spread of Infection
  • Control measures within schools
    • Withdrawal of cooking activities
    • No plasticine, sand or water play
    • Advice on cleaning measures
    • Advice on good hand washing
    • No food brought into schools other than for own consumption
    • Harvest festivals, Christmas parties etc.
detailed investigations
Detailed Investigations
  • Epidemiological Investigations
    • Case definition
    • Case ascertainment
    • Descriptive epidemiology
    • Analytical epidemiology
  • Microbiological Investigations
    • Faecal specimens
    • Food stuffs
    • Environmental samples
  • Environmental Investigations
    • Inspections
results of investigations
Results of Investigations
  • Widespread contamination – no single school
  • Pattern of cases reflected distribution of meat
  • All cases had consumed school meals
  • Samples of meat removed from schools contained the same strain of E.coli O157 as many of the cases
  • E.coli O157 genotype unique to this outbreak
  • Inspection revealed significant shortcomings at meat supplier
  • Primary cases ceased to present within one incubation period of withdrawal of meats
  • OCT confirmed source as cooked sliced meats supplied by J Tudor & Son Butchers
  • Proactive release of information
  • Parents given priority
    • Direct contact
    • Letters to head teachers & schools
    • Letters to parents
    • E.coli O157 Helpline
    • School meetings
  • Daily press updates
    • All releases agreed by OCT
    • Single speaker to ensure consistent message
    • Web sites
  • Communication with health professional
  • Communication with public officials & elected members
summary statistics
Summary & Statistics
  • Declared over on 20th December 2005
  • 157 cases meeting case definition, 118 microbiologically confirmed
  • 44 schools affected across 4 local authorities
  • 109 cases strain of E.coli O157 unique to the outbreak
  • 31 cases hospitalised, 1 death
  • Largest outbreak in Wales, 2nd in UK
politics media
Politics & Media
  • Very high profile
  • Constant & insatiable media attention
  • Intrusive and distracting
  • Role of media & public figures in a public health crisis – social responsibility
communications and media

Communications and Media

Sub judice nature of much of the information to hand

General public concern regarding E. coli

Need for information and informed comment

Need for professional response to political comments

Need for the profession to be seen – by the public and by the profession

chief medical officers review
Chief Medical Officers Review
  • Commissioned by Minister for Health & Social Services
  • Fettered by the ongoing criminal investigation and requirements of confidentiality
  • Evidence gathered was anecdotal and from parties outside the investigation
  • Recommendations of little value
“… the sad news today about the death of young Mason Jones from Bargoed, is devastating to us all. Please can I express my personal gratitude for everything you, and your team, are doing to arrest the E.coli outbreak. I have heard nothing but complimentary remarks about the professional way in which you have conducted yourselves and can reassure you that you have my complete confidence”

Keith Griffiths, Chief Executive of Rhondda Cynon Taf County Borough Council

(4th October 2005)

police investigation
Police Investigation
  • Statements from employees of J Tudor & Son
  • Poor practices revealed:
    • Only ever been one vacuum packer at premises used for raw & cooked meats continually
    • Weighing scales, vacuum packer never cleaned
    • In 3 years a member of staff had never seen any sanitizer at the premises
    • Staff had never seen any temperature readings being taken
    • No stock rotation, staff instructed to reuse decomposing meat
    • High risk equipment only cleaned with a cloth
    • Meat returned by customers would be reused in between slices of good meat
police investigation27
Police Investigation

“There is a large amount of evidence, in the form of witness statements, to indicate that cross contamination from raw to cooked meat was an almost certainty” – Prof. C Griffiths

“It is…my opinion that W Tudor misled and/or gave false information to enforcement officers during visits to the premises. In particular…he had no intention to provide a separate vacuum packing for cooked meats to minimise the risks of cross contamination”

- Colin Houston

dual investigation
Dual Investigation
  • Evidence necessary to make out local authority case available very early
  • Police evidence gathering very complicated, lengthy and expensive
  • Decision on manslaughter charge made by CPS
  • Prosecution took place 2 years after outbreak
  • Much information sub judice for 2 years
  • Public and media frustration at delay
  • Public and media failure to understand charge and sentence
the local authority prosecution
The Local Authority Prosecution
  • Jointly brought by Rhondda Cynon Taf, Caerphilly & Bridgend County Borough Councils
  • 5 charges for placing on the market unsafe food relating to 5 positive meat samples
  • 1 charge for placing on the market unsafe food – relating to Deri Primary school and Mason Jones
  • 1 charge relating to the operation of the food business – failing to ensure that raw & cooked meat was protected against contamination
guilty plea 7 th september 2007
Guilty Plea – 7th September 2007
  • William J Tudor admitted to offences
  • Sentenced to 12 months imprisonment
  • Prohibition from managing a food business
  • No costs awarded
  • Actually served 12 weeks of sentence before release
  • Cost to LAs - £596,000
what have we learned
What have we learned?
  • The Outbreak
  • The Prosecution
  • The Public Inquiry
the outbreak
The Outbreak
  • Key characteristics of E.coli O157
    • Low infective dose/severe symptoms
    • High risk of secondary spread at home
    • Asymptomatic cases/excretion
  • Decision to keep schools open vindicated
  • Communications – internal & external
  • Staff welfare during the outbreak
  • Impact on service delivery
  • Role of Environmental Health – a job well done!
the prosecution
The Prosecution
  • Difficult to reconcile two investigations
  • Frustrating - confidentiality
  • Public Health vs. Criminal
  • Significant resource implications
  • Valuable evidence gathered which supported LA prosecution
  • Could we have brought our prosecution without the Police evidence?
the public inquiry
Response to recommendations

Food Law Enforcement & Inspections


School Toilet Facilities

The Public Inquiry
food law enforcement inspection
Food Law Enforcement & Inspection
  • Food businesses & HACCP
  • Separation of raw & cooked meat
  • “Light touch” enforcement
  • Audit based inspection of HACCP plans
  • Training, experience & competency of EHOs
    • HACCP
    • Management
  • “Red flagging” issues/concerns
  • Evidence based decisions on management confidence
  • Discussions with employees
  • Quality vs. Quantity, Outcomes vs. Process
  • Better quality regulation not less!
procurement of food
Procurement of Food
  • Costs vs. quality & safety
  • Third party audit of suppliers
  • EHO involvement
    • Scrutiny of inspection reports
    • Tendering process
    • Contract monitoring & evaluation
    • Complaints systems

Where is the real risk? – supplier assurance

What about commissioned services & non approved suppliers? – residential care homes, independent schools

school toilet facilities
School Toilet Facilities
  • Provision of hot water, soap, hand drying facilities
  • Audit/inspection of facilities
  • Capital programme of improvements
  • What about management?
  • About infection control in schools per se, not this outbreak!
“Dodgy business people are going to be around forever and a day. And the only thing protecting the public against them is EHPs. But there aren’t enough of them to do this essential job” – Prof. H. Pennington Sept 2009

I am very worried about this continued decline in the esteem EHOs are held in when it comes to their role in protecting public health”

– Prof. H. Pennington – May 2009

“Over the years I’ve worked with a lot of EHOs and I’ve got enormous respect for their practical intelligence and common sense and the way they try and apply themselves. I think it would be very regrettable if the conclusions about any deficiencies that may or may not have occurred in inspection focus on what individuals may or may not have done, because it seems to me that there are a number of institutional issues here that are highly relevant”

- Dr Roland Salmon

lessons for ehps
Lessons for EHPs

Check everything and evidence the response

Record everything (including reasons for recording nothing)

Verify what you are told

Check practice, not process

Identify trends and follow them up

Flag up and follow up concerns

Believe nothing, trust no one, check everything, record everything


Pennington -v- LBRO

Competencies of managers

Dealing with criminals

Red flagging - how suspicious is suspicious? FOI implications

Restrictive inspection protocols – data collection etc




Paul J Mee

01443 425514

Julie Barratt

01633 865533